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A case of combined genital prolapse and rectal prolapse in a 55-year-old multipara is reported. The mixed prolapse was treated by vaginal hysterectomy with pelvic floor repair and laparoscopic rectopexy at the same sitting. The feasibility of combined treatment of genital prolapse by the vaginal route and of rectal prolapse by laparoscopic rectopexy is emphasized.
AIM: The objective was to study the clinical presentation and outcome of intussusceptions prolapsing rectally. METHODS: A retrospective analysis was done of 198 children who presented with intussusception at a single institution over a 5-year period. Of this group, the data of children with intussusception prolapsing rectally was studied. RESULTS: The incidence of prolapsing intussusception in this series was 8%. All 16 patients were infants with an average age of 5 months. The most common presenting features were rectal bleeding and abdominal mass. Only 56% of children had abdominal pain. 4/16 children had abdominal distension and 4 had dehydration. The duration of symptoms was less than 48 hours in 14/16 patients. Air enema reduction (AER) was attempted in 14/16 patients and was successful in 8 patients. The success rate of AER was 57%. One patient developed a perforation during AER. Manual reduction was done in six patients who failed AER and in two patients in whom AER was not attempted because of prolonged duration of symptoms (> 48 hrs). There were no recurrences in this series. CONCLUSION: The incidence of intussusceptions prolapsing rectally is high in this series. It can present in the absence of the cardinal symptoms of intussusception. A high index of clinical suspicion is necessary to make the diagnosis. AER is often successful and must be attempted in children who do not have contraindications for this procedure.
Rectal prolapse and solitary rectal ulcer syndrome are both benign conditions affecting the rectum, mainly in women; prolapse tends to occur late in life, while solitary rectal ulcer syndrome has a predilection for the younger adult. Complete rectal prolapse probably starts as a mid-rectal intussusception, although a combination of this theory and the 'sliding hernia' theory has been proposed by Altemeier et al (1971). The pelvic floor weakness associated with prolapse, which gives rise to incontinence, is most likely due to a traction injury to the pudendal nerve. Anorectal manometry will indicate those incontinent patients likely to benefit from rectopexy. Abnormal descent of the perineum may be found in rectal prolapse and solitary rectal ulcer syndrome as well as descending perineum syndrome per se. The clinical features of these three conditions can overlap. Solitary rectal ulcer syndrome is essentially due to prolapse and traumatization of the rectal mucosa. Inappropriate puborectalis contraction, abnormal perineal descent, and overt rectal prolapse have all been cited as possible mechanisms of development of the condition. Defecography is the radiologic investigation of choice. Electromyography, as in rectal prolapse, may show evidence of pudendal nerve damage although incontinence is rare.
The biopsy diagnosis of prolapsing rectal mucosa syndrome can be difficult. We present two newly described features--'diamond-shaped' crypts and mucosal elastin--which appear to be helpful in histological diagnosis. Of 32 biopsies of prolapsing rectal mucosa syndrome, all showed diamond-shaped crypts or mucosal elastin, and 28 contained both. Control biopsies comprised cases of normal or irritable bowel syndrome (46), irradiation colitis and ischaemic colitis (16), inflammatory bowel disease (26), and adenomas (30). Mucosal elastin and 'diamond-shaped' crypts with distinctive scalloped edges, which were never seen in prolapse, were observed in half the cases of irradiation and ischaemic colitis. Diamond-shaped crypts were seen in one case of inflammatory bowel disease. Diamond-shaped crypts and elastin were seen in the base of adenomas large enough to cause localized prolapse, and in four biopsies from patients with irritable bowel syndrome, all of whom had given a history of straining at stool.
INTRODUCTION: Rectal prolapse, or procidentia, is defined as a protrusion of the rectum beyond the anus. It commonly occurs at the extremes of age. Rectal prolapse frequently coexists with other pelvic floor disorders, and patients have symptoms associated with combined rectal and genital prolapse. Few patients, a lack of randomized trials and difficulties in the interpretation of studies of anorectal physiology have made the understanding of this disorder difficult. METHODS OF TREATMENT: Surgical management is aimed at restoring physiology by correcting the prolapse and improving continence and constipation, whereas in patients with concurrent genital and rectal prolapse, an interdisciplinary surgical approach is required. Operation should be reserved for those patients in whom medical treatment has failed, and it may be expected to relieve symptoms. Numerous surgical procedures have been suggested to treat rectal prolapse. They are generally classified as abdominal or perineal according to the route of access. However, the controversy as to which operation is appropriate cannot be answered definitively, as the extent of a standardized diagnostic assessment and the types of surgical procedures have not been identified in published series. LITERATURE REVIEW: This review encompasses rectal prolapse, including aetiology, symptoms and treatment. The English-language literature about rectal prolapse was identified using Medline, and additional cited works not detected in the initial search were obtained. Articles reporting on prospective and retrospective comparisons and case reports were included.
Over 15 years 108 patients with either rectal prolapse or internal rectal procidentia were treated by the Ripstein operation. Postoperative evaluation was possible in 97 patients (mean observation time, 6.9 years). The mortality rate was 2.8 percent, and surgical complications occurred in an additional 3.7 percent. The recurrence rate was 4.1 percent. Preoperative and postoperative functional analysis was possible in 92 patients. The proportion of continent patients increased from 33 percent preoperatively to 72 percent postoperatively. Defecation difficulties increased from 27 percent to 43 percent following surgery, and were a major cause of dissatisfaction.
PURPOSE: Rectal prolapse typically occurs in elderly patients, who are often poor surgical candidates because of the presence of multiple comorbidities. Abdominal approaches to procidentia have low recurrence rates but are associated with higher rates of morbidity and mortality. Perineal rectosigmoidectomy (Altemeier repair) is a safe and effective approach to the treatment of rectal prolapse and can be done as an outpatient procedure. In this article, the results of a series of 63 consecutive Altemeier repairs are presented. METHODS: Between February 1993 and December 1999, 63 patients (61 females) underwent Altemeier repair of rectal prolapse. The mean patient age was 79 years. Preoperative, intraoperative, and postoperative data were collected and analyzed for all patients. RESULTS: Median follow-up was 20.8 months. Seventy percent of patients were given a regional or local anesthetic. The average resected specimen length was 11.6 cm, and 83 percent of anastomoses were stapled. Sixty-two percent of patients were discharged home on the day of surgery, and 80 percent were home within 24 hours. Complications occurred in 10 percent of patients, but there was no perioperative mortality. There was a 6.4 percent recurrence rate, and all recurrences were successfully treated with repeat Altemeier repair. All 63 patients had complete objective resolution of prolapse, and 87 percent had subjective improvement after repair. CONCLUSIONS: Altemeier repair of rectal prolapse is safe, produces minimal discomfort, and does not require a general anesthetic. It is ideally suited to be done on an outpatient basis, as was done in the majority of patients in our series. The recurrence rate is slightly higher than with abdominal resections, but morbidity and cost are lower, and repeat perineal resections are easily and safely performed.
Total rectal prolapse is a disabling disease. The aim of this study was to evaluate pain management, hospital stays, constipation, and continence status among military personnel who underwent laparoscopic surgery. Forty patients (mostly men) underwent laparoscopic rectopexy (LR) or laparoscopic resection rectopexy (LRR). Colonic transit time, postoperative pain scores, preoperative and postoperative anal function, and changes in constipation were assessed. The median operation times for LR and LRR were 126 and 223 minutes, respectively. The median postoperative hospital stays were 3 and approximately 6 days for LR and LRR, respectively. Patients needed fewer analgesics in a short postoperative period. However, there was no difference between the two groups in analgesic requirements. Continence improved for approximately 71% of patients, but constipation was treated for 50% of affected patients. No recurrences were noted in the follow-up periods, which were 13 and 22 months for the LRR and LR groups, respectively. The quality of life for the patients who underwent LR was not as good as that for the patients who underwent LRR, at the end of 1 year. We eliminated total rectal prolapse and almost cured incontinence by using laparoscopy, although the disadvantageous aspects were long operation times and suboptimal healing with respect to constipation and related symptoms. LRR is the more feasible procedure, with the emphasis on elimination of incontinence and constipation, producing a better quality of life for patients, in addition to short hospitalizations, necessity for analgesia for a short time, and return to hard training field activities in a short time among military personnel.
Incarcerated rectal prolapse is a potential surgical emergency. We report a case in which a simple but effective technique involving the desiccating effect of granulated sugar (sucrose) was used to aid the manual reduction of prolapsed but viable rectal tissue.
Recurrent rectal prolapse or postoperative rectal stricture occurred in four of 88 patients (4.5 per cent) who underwent Teflon sling repair at the Lahey Clinic during the past 15 years. Management of these and six other similar patients referred for treatment suggests that young men appear to be at a higher risk for recurrence. Strictures may be more likely to develop in patients with a long history of prolapse or problems with constipation. Teflon sling repair followed by recurrent prolapse or stricture formation should probably be treated by low anterior resection.
Rectal prolapse in pediatrics has its highest incidence in infancy and is uncommonly seen in industrialized countries. The prolapse may involve only the mucosa (mucosal prolapse) or all layers of the rectum (complete prolapse or procidentia). It is usually detected by the child's parents and is brought urgently to medical attention; however, it is usually spontaneously reduced by the time they reach the practitioner's office. Rectal prolapse should be viewed as a symptom of an underlying condition rather than a discrete disease entity. Potential causes are increased intraabdominal pressure, diarrheal and neoplastic diseases, malnutrition, and conditions predisposing to pelvic floor weakness. Its strong association with cystic fibrosis makes the sweat test mandatory for infants and children with recurrent rectal prolapse. Of particular importance are three entities related to rectal prolapse that may easily escape diagnosis by practitioner: occult rectal prolapse, solitary ulcer of the rectum syndrome, and inflammatory cloacogenic polyps. The treatment of rectal prolapse is mainly conservative and is directed at the underlying conditions. Surgical intervention may be required for recurrent rectal prolapse refractory to conservative measures. The simplest, less invasive, yet highly effective approach, appears to be perirectal injection with a sclerosing agent. While the majority of children experience spontaneous resolution of the prolapse, the prognosis is worse when presentation occurs after the age of 4 years.
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OBJECTIVE: An 'occult' rectal prolapse may be diagnosed during investigation of altered bowel habit. It has been suggested that the outcome of surgery for these patients may be associated with results that are inferior to those achieved in patients with overt rectal prolapse. This study compares the results of surgery for 'occult' and overt rectal prolapse in terms of mortality, morbidity and change in bowel habit. PATIENTS AND METHODS: A retrospective review was undertaken of consecutive patients undergoing surgery for rectal prolapse during the decade 1988-98. Resection rectopexy was the treatment of choice except in patients with faecal incontinence who underwent sutured rectopexy. Those patients who were unfit for an abdominal operation were offered a perineal procedure. Outcome measures were mortality, morbidity, prolapse recurrence, constipation and faecal incontinence. Data were retrieved from case note review, clinical assessment, telephone consultation or postal questionnaire. RESULTS: Rectal prolapse surgery was undertaken in 69 patients with an overt prolapse and 74 patients with an 'occult' prolapse. Patients in the 'occult' prolapse group were significantly younger than those with overt prolapse (P = 0.0002). There were significantly more perineal procedures in the overt prolapse group compared with the 'occult' prolapse group (54% vs 5%, P = 0.0001). There were no deaths within 28 days of surgery. Major surgical complications occurred in 5 patients (3.5%). Seven patients (10%) experienced recurrent prolapse. Rectal prolapse surgery reduced the incidence of St. Mark's grade 4 faecal incontinence from 38% to 19% in the overt prolapse group (P = 0.023) and from 49% to 22% in the 'occult' prolapse group (P < 0.001). Following surgery the incidence of constipation increased in the 'occult' group from 39% to 50% but decreased in the overt prolapse group from 42% to 35%. CONCLUSIONS: Surgery for an 'occult' rectal prolapse is unlikely to benefit patients whose principle symptom is constipation. Approximately half of those patients whose 'occult' rectal prolapse is associated with faecal incontinence will have their bowel habit improved by prolapse surgery.
Rectal prolapse is not uncommon in the pediatric age group. Occurring more frequently in boys than girls and most often during the period of toilet training, the condition is usually self-limited. Treatment typically consists of nonoperative measures. There are patients, however, in whom operative intervention becomes necessary. Operative procedures described are based largely on adult experience and the most common repairs involve the use of a foreign body (Ripstein procedure) or colonic resection. These procedures are of considerable magnitude and may be attended by significant morbidity. As a result, there is reluctance to apply these techniques in children. There exists, then, a place for an efficacious method of repair for large prolapses that incurs minimal morbidity. This report recounts our experience with the treatment of four children with rectal prolapse using a transsacral rectopexy. The results indicate minimal perioperative morbidity, discharge within a few days, with the mechanisms of fecal continence being preserved. The longest follow-up is 17 years with a mean follow-up of 9 years. The overall treatment of rectal prolapse in children is reviewed with specific emphasis upon the indications for and technique of the transsacral approach.
PURPOSE: Total rectal prolapse is a devastating disorder causing constipation and anal incontinence. We compared open and laparoscopic surgical approaches in a limited series. METHODS: The subjects of this study were 23 patients who underwent laparoscopic procedures (LP group) and 17 patients who underwent open procedures (OP group) for rectal prolapse. We assessed the preoperative colonic transit time, postoperative pain scoring, pre- and postoperative anal functions, and changes in constipation and related symptoms. RESULTS: The median operation time was 140.8 min for the LP group and 113.1 min for the OP group (P = 0.037). The median postoperative hospital stay was 4.8 days after the LPs and 9.6 days after the OPs (P = 0.001). Less analgesia was needed in the early postoperative period after the LPs (P = 0.007). While more than 70% improvement in continence was seen in the patients who underwent OPs, it was about 85% in those who underwent LPs. Improvement in constipation and related symptoms were similar in both groups. More than 30% of patients still suffered from hard stools and other symptoms of constipation. The colonic transit times were reduced in about 50% of patients who had suffered constipation in both groups. There was no incidence of recurrence in the median follow-up period. CONCLUSION: Although transabdominal rectopexy has been performed conventionally for rectal prolapse for many years, laparoscopic rectopexy and laparoscopic resection rectopexy are associated with lower morbidity and less postoperative pain. We eliminated the total prolapse and cured incontinence in almost all patients, with a short hospital stay.
The association of genital prolapse and rectal prolapse is rare. The authors report six cases of simultaneous mixed prolapse treated surgically via an abdominal approach. The latter technique enables the treatment of genital prolapse by uterine fixation to the promontory and rectal prolapse by rectopexy using the Orr-Loygue technique. Chronic constipation and obstetric trauma are constantly found among etiological factors. Four of our patients had urinary stress incontinence. There were no preoperative complications. One patient reported worsening of her constipation. Mean follow-up is only 20 months (2 months to 3 years), but no recurrences have occurred. Review of the literature and of series with more than fifteen years follow-up shows that the Orr-Loygue operation is reliable with a low complication rate and only rare recurrences.
The rectal sling procedure has been used successfully in treating rectal prolapse for over three decades. Recurrences are rare; however, difficulties have developed from excessive reaction to some prosthetic slings and the failure of others to allow tissue ingrowth. Gore-Tex is presented as an ideal material for correction of the rectal sling because of its inert properties and porous structure which allows tissue incorporation. The problem of postoperative fecal impaction created by pulling the sling too tight has also been circumvented by placing the sling posteriorly, leaving the anterior rectal wall free to distend. The Ripstein procedure is described in detail, and a series of 23 patients is presented who have had successful rectal prolapse repair using the new rectal sling procedure. There have been no recurrences and minimal morbidity in these cases.